State of the Union 2014: The search for a non-awkward Obamacare shout-out
By: David Nather January 27, 2014 05:05 AM EDT

This time, President Barack Obama is going to have to actually talk about Obamacare in his State of the Union address.

No more touch-the-base-and-keep-running treatments, the way he’s handled it the past couple of years. This time, he’ll be expected to linger on base a bit, at least long enough to acknowledge the launch of the biggest domestic achievement of his presidency — and do it in the least awkward way possible.

That’s the consensus of Democratic strategists, health care experts, pollsters and crisis-management experts, all of whom will have reasons to listen closely when Obama brings up the health care law on Jan. 28. It will be Obama’s most high-profile address since the clunky rollout began, and although it has come a long way since the worst days of October, it’s still not enough for him to say, “Nailed it.”

Instead, Obama will have to find an uplifting message about the law that doesn’t imply that everything’s suddenly back on track. The most he can say, based on the latest developments, is that “it’s moving back toward the track,” said Len Nichols, director of the Center for Health Policy Research and Ethics at George Mason University.

The federal enrollment website, HealthCare.gov, is working much better than it was in October, and sign-ups for private health coverage sped up dramatically in December. Now 3 million Americans have selected private health insurance plans, and there’s time for one more wave before enrollment ends March 31. And CGI, the main contractor on the botched website, has been shown the door.

That doesn’t mean the Obama administration can put its fire extinguishers away though. The age mix isn’t right yet with too many older adults and not enough younger ones. The early sign-ups in the exchanges may not include a lot of actual uninsured people, although some have probably been added through Medicaid. Insurers are still waiting for the “back end” of the website, the part that handles their payments, to be built.

And HealthCare.gov’s Facebook page is loaded with complaints about enrollment problems, like customers who say they couldn’t get any proof of coverage from their insurance companies, couldn’t get coverage for their kids or are bouncing back and forth between the website and insurance call centers to try to resolve errors.

The bottom line: Obama needs a speech that rallies the faithful without losing credibility with the rest of the country.

There’s actually a fairly easy formula, according to the strategists and health care analysts, and it doesn’t require a radical departure from what Obama has already said about the law. He needs to say that millions of people have already signed up for coverage — though he shouldn’t overstate how many. He should say that millions more who already have health coverage have gotten new benefits, like preventive care with no copayments. He has acknowledged the bad rollout, but tell the law’s most enthusiastic supporters that “we’ve turned the corner.”

Most of all, Democratic strategists say, he has to revive his message that “we’re not going back.”

“I don’t think he is going to try and resell that everything is perfect, but I would remind people that we can’t go back to a time when insurance companies were running the health care system and deciding who gets to participate,” said Democratic pollster John Anzalone. “No more getting denied coverage because of pre-existing conditions, no more being priced out of the marketplace because of DNA (pre-existing conditions), no more lifetime limits, no more having to file bankruptcy because a family has a medical emergency.”

Obama has said all of that before, but now that people are actually getting health coverage and other benefits, Democrats say the reminder is more important than ever.

“Americans do not like having their rights taken away. And they do not like the idea of the GOP taking away their newfound health care rights,” said Paul Begala, a former adviser to President Bill Clinton.

Health care didn’t occupy a lot of time in Obama’s last three State of the Union addresses since the law was signed. In 2011, Obama acknowledged that the new House Republican majority hated the law, said it can always be improved but vowed never to go back to the days when insurance companies could turn people down because of pre-existing conditions. In 2012 and 2013, Obamacare was reduced to a walk-on role — a couple of quick sentences, and that was it.

This year, the speech is expected to be built around the sweeping theme of reducing economic inequality, so the health care law still can’t take up more than a small piece of it. But now that the major parts are finally going into effect, and the rollout was such an all-consuming national story, Obama can’t gloss over it without looking like he’s intentionally avoiding the subject.

“You can’t hide from this. The story will be bigger if you do,” said Marlin Collingwood, president of CHT Group, a Boston-based firm that specializes in crisis communications.

Collingwood said the speech would be a good time to use the kind of self-deprecating humor Obama has used in other bad situations. “He can just say, ‘Yeah, we’ve had a rough couple of months,’” he said. “But then he’s got to move past that quickly and talk about the benefits.”

The White House isn’t tipping its hand on what approach Obama will take, but there’s one powerful storytelling technique that pretty much everyone is expecting him to use: First lady Michelle Obama will have a guest in the audience who has gotten health care coverage for the first time, allowing the president to tell a powerful story that makes it harder for Republicans to keep pushing for repeal.

“If there’s a family that’s gotten health insurance for the first time, that’s a story that’s very hard to ridicule,” said Collingwood.

Some Democrats say it wouldn’t be too hard for Obama to link the health care law to the economic inequality theme as one part of the larger storyline he wants to define the rest of his presidency.

Democratic strategist Chris Lehane predicted that the law’s expansion of health coverage will be folded into the inequality theme — “that for our democracy to flourish, we need to address the vast and growing inequalities by increasing access to higher education; moving forward on health care for all; investing in the jobs of the future; making sure that people get a fair day’s pay for a fair day’s work.”

That approach carries some risks though because “it gets into winners and losers,” and Obama’s audience may react badly to the idea that some people will pay higher costs to help more vulnerable people, said Robert Blendon, an expert on health care public opinion at Harvard University.

The better approach, he said, would be for Obama to talk more narrowly about “protecting people from the costs of health care without talking so much about narrowing the gap.”

Obama faces one especially tricky challenge: He has to talk to different audiences with wildly different feelings about the health care law. Republicans are rigidly against it, of course, but independents are skeptical, too, and they won’t be convinced by feel-good talking points that ignore the rollout problems.

Democrats, on the other hand, will want Obama to talk about the cause that’s so close to their hearts — and the one Obama pushed through Congress largely because they wanted it.

“For Democrats, this is really a litmus test. They’re going to want to hear him say their work has paid off, and we’ve turned the corner, and we’re moving ahead,” said Blendon.

But has it really turned the corner? Health care experts say it’s too soon to say, and it certainly won’t be clear until enrollment ends in March and the final signup numbers come in.

“Certainly, the huge enrollment numbers for December are very good news, but (1) there’s still quite a bit of ground to make up in the next 3 months, so will the momentum continue? (2) Will the back-end stuff work to complete enrollment, invoicing and payment for millions of people? Once both questions are answered in the affirmative, I think the ACA is back on track,” Jon Kingsdale, a consultant who ran the Massachusetts health insurance exchange that predated Obamacare, wrote in an email.

Nichols, however, says it’s a good sign that health insurers don’t seem too worried about not having enough young adults in the mix yet.

“They’re not panicked. Why are they not panicked? Because they know this is normal,” Nichols said. “Sure, the sick people came in first, but there are three more months.”